Background Obesity and physical inactivity are responsible for more than 365,000 deaths per year and contribute substantially to rising healthcare costs in the US, making clear the need for effective public health interventions. Calorie labeling on menus has been implemented to guide consumer ordering behaviors, but effects on calories purchased has been minimal. Methods In this project, we tested the effect of physical activity calorie expenditure (PACE) food labels on actual point-of-decision food purchasing behavior as well as physical activity. Using a two-group interrupted time series cohort study design in three worksite cafeterias, one cafeteria was assigned to the intervention condition, and the other two served as controls. Calories from food purchased in the cafeteria were assessed by photographs of meals (accompanied by notes made on-site) using a standardized calorie database and portion size-estimation protocol. Primary outcomes will be average calories purchased and minutes of moderate to vigorous physical activity (MVPA) by individuals in the cohorts. We will compare pre-post changes in study outcomes between study groups using piecewise generalized linear mixed model regressions (segmented regressions) with a single change point in our interrupted time-series study. The results of this project will provide evidence of the effectiveness of worksite cafeteria menu labeling, which could potentially inform policy intervention approaches. Discussion Labels that convey information in a more readily understandable manner may be more effective at motivating behavior change. Strengths of this study include its cohort design and its robust data capture methods using food photographs and accelerometry.

Recently, the US Preventive Services Task Force issued a draft recommendation to utilize 24‐hour ambulatory blood pressure (BP) monitoring (ABPM) to confirm the diagnosis of hypertension after screening. However, ABPM can be inconvenient and has some adverse effects such as pain and bruising from the repeated cuff inflations. In this national survey, we asked adults 30 years and older how much physical discomfort they would be willing to undergo to have the most accurate test available for evaluating possible high BP. We also asked how much they would be willing to pay to have the test. Among 1010 respondents, 95% of participants indicated willingness to undergo at least mild physical discomfort. The median amount people would be willing to pay was $25. These findings suggest that people are willing to undergo a bit of discomfort, and even pay a small amount, for the benefit of accurate BP assessment.

Hypokalemia and hyperkalemia are common electrolyte disorders caused by changes in potassium intake, altered excretion, or transcellular shifts. Diuretic use and gastrointestinal losses are common causes of hypokalemia, whereas kidney disease, hyperglycemia, and medication use are common causes of hyperkalemia. When severe, potassium disorders can lead to life-threatening cardiac conduction disturbances and neuromuscular dysfunction. Therefore, a first priority is determining the need for urgent treatment through a combination of history, physical examination, laboratory, and electrocardiography findings. Indications for urgent treatment include severe or symptomatic hypokalemia or hyperkalemia; abrupt changes in potassium levels; electrocardiography changes; or the presence of certain comorbid conditions. Hypokalemia is treated with oral or intravenous potassium. To prevent cardiac conduction disturbances, intravenous calcium is administered to patients with hyperkalemic electrocardiography changes. Insulin, usually with concomitant glucose, and albuterol are preferred to lower serum potassium levels in the acute setting; sodium polystyrene sulfonate is reserved for subacute treatment. For both disorders, it is important to consider potential causes of transcellular shifts because patients are at increased risk of rebound potassium disturbances.

OBJECTIVES:Menu labels displaying food energy in physical activity calorie equivalents (PACE) is a possible strategy to encourage ordering meals with fewer calories and promoting physical activity. Potential effects of such labeling for children have never been examined.METHODS:We conducted a national survey of 1000 parents randomized to 1 of 4 fast food menus: no labels, calories only, calories plus minutes, or calories plus miles needed to walk to burn the calories. Respondents were asked to imagine they were in a fast food restaurant and place an order for their child. At the survey's conclusion, all respondents were shown a calorie-only label and both PACE labels and asked to rate the likelihood each label would influence them to encourage their child to exercise.RESULTS:We excluded respondents whose meals totaled 0 calories or >4000 calories, leaving 823 parents in the analysis. The mean age of the child for whom the meal was "ordered" was 9.5 years. Parents whose menus displayed no label ordered an average of 1294 calories, whereas those shown calories only, calories plus minutes, or calories plus miles ordered 1066, 1060, and 1099 calories, respectively (P = .0001). Only 20% of parents reported that calories-only labeling would be "very likely" to prompt them to encourage their children to exercise versus 38% for calories plus minutes (P < .0001) and 37% for calories plus miles (P < .0001).CONCLUSIONS:PACE labeling may influence parents' decisions on what fast food items to order for their children and encourage them to get their children to exercise.

Plasma renin activity (PRA)-guided therapy has been proposed as a strategy for selecting antihypertensive medications matched to the patient's underlying pathophysiology. To date, there are only a few studies that have sought to compare a PRA-guided strategy to usual care. In one trial of 363 untreated patients, based on home blood pressure (BP) averages, PRA was predictive of responses to beta-blocker and thiazide diuretic as monotherapy and add-on therapy. In another trial of 77 treated but uncontrolled patients, a PRA-guided strategy was superior to clinical hypertension specialist care for guiding add-on or subtraction (stopping an agent that might cause a paradoxical pressor response) therapy. In the ValVET study, PRA-guided therapy was not superior to fixed-dose therapy consisting of an angiotensin receptor blocker and hydrochlorothiazide. One modeling study found a PRA-guided strategy may be cost-effective compared to standard care for younger patients and those with a greater number of cardiovascular risk factors. We conclude that additional, well-designed randomized trials with sufficient sample sizes comparing PRA-guided management to usual care are needed to clarify whether this strategy should be adopted broadly.

Objective Masked hypertension (MH) refers to nonelevated office blood pressure (BP) with elevated out-of-office BP, but its reproducibility has not been conclusively established. We examined 1-week reproducibility of MH by home BP monitoring (HBPM) and ambulatory BP monitoring (ABPM).Methods We recruited 420 adults not on BP-lowering medication, with recent clinic BP between 120/80 and 149/95 mmHg. For main comparisons, participants with office average less than 140/90 mmHg were considered to have MH if awake ABPM average was 135/85 mmHg or higher; they were considered to have MH by HBPM if the average was 135/85 mmHg or higher. Percentage agreements were quantified in terms of.. We also examined the prevalence of MH, defined as office average less than 140/90 mmHg, with a 24-h ABPM average of 130/80 mmHg or higher. We carried out sensitivity analyses using different threshold BP levels for ABPM-office pairings and HBPM-office pairings for defining MH.Results Prevalence rates of MH based on office-awake ABPM pairings were 44 and 43%, with an agreement of 71% (kappa = 0.40; 95% confidence interval 0.31-0.49). MH was less prevalent (15 and 17%) using HBPM-office pairings, with agreement of 82% (kappa = 0.30; 95% confidence interval 0.16-0.44), and more prevalent when considering the 24-h average (50 and 48%). MH was also less prevalent when more stringent diagnostic criteria were applied. Office-HBPM pairings and office-awake ABPM pairings had fair agreement on MH classification on both occasions, with kappa-values of 0.36 and 0.30.Conclusion MH has fair short-term reproducibility, providing further evidence that for some people, out-of-office BP is systematically higher than that measured in the office setting. (C) 2014 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

Hypertension is the most common modifiable risk factor for cardiovascular disease. Antihypertensive treatment substantially reduces the risk of heart failure, stroke, and myocardial infarction. Current guidelines recommend screening all adults for high blood pressure (BP). Lifestyle modifications to help control high BP include weight loss, exercise, moderation of alcohol intake, and a diet low in sodium and saturated fats and high in fruits and vegetables. Out-of-office BP monitoring should be used to confirm suspected white coat effect, especially in patients with apparent resistant hypertension.

Nighttime blood pressure (BP) dipping can be quantified as the ratio of mean nighttime (sleep) BP to mean daytime (awake) BP. People whose dipping ratio is ≥0.90 have been referred to as nondippers, and nondipping is associated with cardiovascular disease events. We examined the relationship between systolic nighttime BP dipping in young adults and the presence of coronary artery calcium (CAC) 10 to 15 years later using data from the ambulatory BP monitoring substudy of the Coronary Artery Risk Development in Young Adults Study. Among 239 participants with adequate measures of both nighttime and daytime readings and coronary artery calcium, the systolic BP dipping ratio ranged from 0.72 to 1.24 (mean, 0.88; SD, 0.06), and CAC was present 10 to 15 years later in 54 participants (22.6%). Compared with those whose systolic BP dipping ratio ranged from 0.88 to 0.92 (quartile 3), the 57 participants (23.9%) with less pronounced or absent dipping (ratio, 0.92–1.24; quartile 4) had an unadjusted odds ratio of 4.08 (95% CI, 1.48–11.2) for the presence of CAC. The 60 participants (25.1%) with a more pronounced dipping (ratio, 0.72–0.85; quartile 1) also had greater odds for presence of CAC (odds ratio, 4.76 [95% CI, 1.76–12.9]). When modeled as a continuous predictor, a U-shaped relationship between systolic BP dipping ratio and future CAC was apparent and persisted after adjustment for multiple potential confounders ( P <0.001 for quadratic term). Both failure of systolic BP to dip sufficiently and “overdipping” during nighttime may be associated with future subclinical coronary atherosclerosis.

Screening often leads to finding conditions that are not at the stage or level that would classify them as disease but, at the same time, are not at a stage or level at which people can be declared entirely disease free. These "in-between" states have sometimes been designated as "predisease." Examples include precancerous lesions, increased intraocular pressure ("preglaucoma"), prediabetes, and prehypertension. When the goal of preventing adverse health outcomes is kept in mind, this review poses the idea that "predisease" as a category on which to act makes sense only if the following 3 conditions are met. First, the people designated as having predisease must be far more likely to develop disease than those not so designated. Second, there must be a feasible intervention that, when targeted to people with predisease, effectively reduces the likelihood of developing disease. Third, the benefits of intervening on predisease must outweigh the harms in the population. A systematic review of screening guidelines (published in 2003-2010) for 4 sample conditions (cervical cancer, glaucoma, diabetes, and hypertension) is included to assess whether they address these issues, followed by a discussion of the framework questions as they pertain to each condition.

Purpose of review The term ‘polypill’ denotes a single-pill combination of drugs for reducing cardiovascular disease events. The ‘polypill strategy’ refers to making such a pill available to the population based on age (e.g. 55 years) rather than individually as a result of a clinical decision. This review summarizes recent studies describing physicians’ perspectives regarding the polypill. Recent findings Among 58 physicians in Sri Lanka, 86% likely would prescribe a polypill for primary prevention if a large trial showed it reduced the risk of major cardiovascular disease events. A study of 952 US physicians found that 83% likely would prescribe a polypill for high-risk patients and 62% likely would do so for moderate-risk patients. Among physicians in both countries, degree of risk reduction was an important factor in willingness to prescribe. Other factors considered important were side effects and cost. Physicians had low agreement with forgoing risk factor level monitoring in patients taking a polypill. The majority (89%) of US physicians surveyed would not want a polypill available without a prescription. Summary Current physician acceptance of the polypill seems moderate to high, at least when considering a clinical approach to its use. As trial publications emerge, it is possible that physician perspectives may evolve toward greater acceptance of a population-health approach to the implementation of a polypill.

Nondippers (people whose sleep systolic blood pressure [SBP] fails to decrease >10% from daytime SBP) have increased risk of cardiovascular disease. The prevalence of nondipping in younger adults has not been well studied, nor has its value for predicting hypertension. We examined the prevalence of nondipping in a substudy of the Coronary Artery Risk Development in Young Adults (CARDIA) Study. We used Cox regression to estimate the hazard ratio (HR) conferred by nondipping for incident prehypertension or hypertension (preHTN/HTN) over 15 years. Of the 264 nonhypertensive participants at baseline, 118 (45%) were nondippers. Blacks were more likely than whites to be nondippers (52% versus 33%, P = .004). The incidence rate of preHTN/HTN was 29.2/1000 person-years among dippers and 36.2/1000 person-years among nondippers. Compared with those in the lowest quartile of nighttime to daytime SBP, those in the highest quartile were more likely to develop preHTN/HTN (HR 1.61; P = .06), but this relationship was attenuated after adjustment (HR 1.34; P = .27). Our results demonstrate that nondipping is common in young, nonhypertensive adults, and is more common in blacks than whites. Nondipping might predate a meaningful clinically detected increase in BP in some people, but more research in larger study samples is needed.

Failure to adjust hypertension therapy despite elevated blood pressure (BP) levels is an important contributor to lack of BP control. One possible explanation is that small elevations above goal BP are not concerning to clinicians. BP levels farther above goal, however, should be more likely to prompt clinical action. We reviewed 1 year's worth of primary care records of 3742 North Carolina Medicaid recipients 21 years and older with hypertension (a total of 15,516 office visits) to examine variations in hypertension management stratified by level of BP above goal and the association of BP level above goal with documented antihypertensive medication change. Among the 53% of patients not at goal BP, 42% were within 10/5 mm Hg of goal; 11% had a BP 40/20 mm Hg or higher above goal. Higher level of BP above goal was independently associated with antihypertensive medication change. Compared with visits at which BP was less than 10/5 mm Hg above goal, the adjusted odds of medication change were 7.9 (95% Confidence Interval 6.2-10.2) times greater at visits when patients' BP was 40/20 mm Hg or higher above goal. However, even when BP was above goal at this level, treatment change occurred only 46% (95% Confidence Interval 40.2-51.8) of the time.

Secondary hypertension is a type of hypertension with an underlying, potentially correctable cause. A secondary etiology may be suggested by symptoms (e.g., flushing and sweating suggestive of pheochromocytoma), examina- tion findings (e.g., a renal bruit suggestive of renal artery stenosis), or laboratory abnormalities (e.g., hypokalemia suggestive of aldosteronism). Secondary hypertension also should be considered in patients with resistant hyper- tension, and early or late onset of hypertension. The prevalence of secondary hypertension and the most common etiologies vary by age group. Approximately 5 to 10 percent of adults with hypertension have a secondary cause. In young adults, particu- larly women, renal artery stenosis caused by fibromuscular dyspla- sia is one of the most common secondary etiologies. Fibromuscular dysplasia can be detected by abdominal magnetic resonance imag- ing or computed tomography. These same imaging modalities can be used to detect atherosclerotic renal artery stenosis, a major cause of secondary hypertension in older adults. In middle-aged adults, aldosteronism is the most common secondary cause of hyperten- sion, and the recommended initial diagnostic test is an aldosterone/ renin ratio. Up to 85 percent of children with hypertension have an identifiable cause, most often renal parenchymal disease. Therefore, all children with confirmed hypertension should have an evaluation for an underlying etiology that includes renal ultrasonography.

BACKGROUND We examined short-term reproducibility of masked hypertension (MH) among adults with recent"borderline"office blood pressure (BP) and compared agreement of ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM) in detecting MH.METHODS Fifty participants underwent repeated office BP measurements, 24-h ABPM, and HBPM sessions 1-week apart. Participants with office average <140/90 mm Hg were considered to have MH if daytime ABPM average was >= 35/85 mm Hg; they were considered to have MH by HBPM if the average was >= 135/85 mm Hg. Agreements were quantified using K. We calculated sensitivity and specificity of daytime ABPM-office average pairing and HBPM session-office average pairing for diagnosing MH using a "standard"of two pairings of office and 24-h average ABPM (using a cutoff >= 130/80 mm Hg).RESULTS Prevalence rates of MH based on office-daytime ABPM pairings were 54 and 53%, with agreement of 73% (K = 0.47; 95% confidence interval (Cl) 0.21-0.72). MH was less prevalent (43 and 35%) using HBPM-office pairings, with agreement of 69% (K = 0.34; 95% Cl 0.06-0.62). Office-HBPM pairings and office-daytime ABPM pairings had poor agreement on MH classification on both occasions, with K of -0.06 and 0.10. Sensitivity and specificity of daytime ABPM-office pairing were 93 and 83%. Sensitivity and specificity of HBPM-office pairing were 23 and 67%.CONCLUSIONS MH appears to have fair-to-moderate reproducibility, favoring the hypothesis that office BP measurement systematically fails to identify some patients who should be treated as hypertensive. HBPM may not be adequate for detecting MH, or may identify a different"type"of MH than ABPM.

Background: Labeling patients as hypertensive has some negative effects. The effects of being labeled as having prehypertension are unknown. We examined whether the label of prehypertension exerts a negative effect on patients' perceived health and whether it motivates people to adopt lifestyle recommendations to prevent hypertension. Methods: We randomized 97 prehypertensive adults to either a labeling message or a generic (no label) message. At 3 months we assessed self-reports of change in perceived health and reported adoption of lifestyle recommendations to try to prevent hypertension. Results: Except for more participants with asthma in the label group, the 2 groups were similar at baseline. Among the 70 participants who provided 3-month follow-up data, 18 people (56%) in the no-label group and 22 people (58%) in the label group reported their health as the same; 13 people (41%) in the no label group and 16 people (42%) in the label group reported health as better; and 1 person (in no label group) reported his health as worse. At 3 months there were no differences in reports of changing eating habits (risk ratio [RR], 1.06; 95% CI, 0.86–1.31), cutting down on salt (RR, 0.99; 95% CI, 0.84–1.15), reducing alcohol intake (RR, 1.23; 95% CI, 0.80–1.90), or exercising (RR, 1.17; 95% CI, 0.91–1.51) to try to prevent hypertension. Conclusion: Being labeled as prehypertensive seems to exert neither harmful nor helpful effects.

Coronary heart disease is the most common cause of death in the United States. The conventional risk factor approach to primary prevention excludes many patients who could benefit from preventive therapies. A global risk approach allows more accurate estimates of risk to guide clinical primary prevention efforts. Global risk of coronary heart disease is a calculation of the absolute risk of having a coronary heart disease event (e.g., death, myocardial infarction) over a specified period. It is based on an empiric equation that combines major risk factors, such as blood pressure and cholesterol levels. When physicians know a patient's global risk of coronary heart disease, they are more likely to prescribe risk-reducing therapies such as antihypertensives, statins, and aspirin. In addition, patients who know their risk level are more likely to initiate risk-reducing therapies. Many tools are available to estimate global risk, including several Web-based calculators. In the United States, tools based on the Framingham Heart Study are recommended.

BACKGROUND:We sought to assess primary care patients' current knowledge about various aspects of high blood pressure (BP).METHODS:We mailed a questionnaire to 700 hypertensive patients enrolled in a practice-based research network cohort from 24 practices in North Carolina. We determined percentages of respondents (total and by subgroups) incorrectly answering each of 6 questions pertaining to various aspects of high BP. We then examined bivariate and multivariate associations with answering 2 or more items incorrectly ("lower hypertension knowledge").RESULTS:We received 530 completed surveys (76% response rate). Twenty-six percent (95% CI, 22-30) of respondents did not know that most of the time people with high BP do not feel it. Twenty-two percent (95% CI, 18-26) either were not sure whether anything could be done to prevent high BP or believe that there is nothing that can be done. Nineteen percent (95% CI, 16-22) either believe taking medications will cure high BP or are not sure whether it will. Twenty-two percent (95% CI, 19-26) of respondents had overall lower hypertension knowledge. Independent associations with lower hypertension knowledge were African-American race (odds ratio, 1.77; 95% CI, 1.10-2.86), having less than high school education (odds ratio, 2.43; 95% CI, 1.34-4.41), and history of stroke/mini-stroke (odds ratio, 1.94; 95% CI, 1.00-3.75).CONCLUSIONS:Patients may need to be taught the difference between curing hypertension and treating it with medications. Efforts to educate the public that lifestyle modifications can prevent hypertension and that it usually causes no symptoms need to continue. It seems especially important to develop messages that reach African-Americans and people with less education.

Routine lifestyle modification advice for managing high blood pressure (BP) is of questionable effectiveness. Using data from the 2005 Behavior Risk Factor Surveillance System, we examined whether receipt of advice is associated with reported adoption of lifestyle modifications. We determined proportions of hypertensive adults taking action to change eating habits, reduce salt intake, exercise, or decrease alcohol consumption to control high BP. We then determined associations between reports of advice given and corresponding actions being taken: 70.1% of respondents reported changing eating habits, 78.7% reported reducing salt intake, 67.1% reported exercising, and 57.9% of those who drank alcohol reported decreasing their consumption. Compared with those who did not recall being given advice, hypertensive adults who recalled being given advice were more likely to change their eating habits (prevalence ratio [PR], 1.62; 95% confidence interval [CI], 1.56–1.67), reduce salt (PR, 1.53; 95% CI, 1.48–1.58), exercise (PR, 1.41; 95% CI, 1.36–1.47), and reduce alcohol consumption (PR, 1.78; 95% CI, 1.70–1.87).